Hemorrhoid

Hemorrhoid

1. Hemorrhoid Mohammed AlHinai

2. Anatomy of anal canal

3. Hemorrhoids : Dilated submucosa vascular structures in the anal canal, arising by Abnormal distension of the arteriovenous ( mainly arterial anastomoses within the hemorrhoidal cushions arise from the inferior hemorrhoidal cushion. covered by modified squamous epithelium (thick layer). contains numerous somatic pain receptors which painful on thrombosis arise from the superior hemorrhoidal cushion . three primary locations  (3,7,11) oclock position overlying columnar epithelium (thin layer) is viscerally innervated  not sensitive to pain, touch, or temperature

4. Classification of internal Hemorrhoids : internal hemorrhoids are graded according to the degree to which they prolapse from the anal canal.

5. Risk factor: advancing age Diarrhea and chronic constipation. Pregnancy pelvic tumors prolonged sitting Straining patients on anticoagulation and antiplatelet therapy Pathogenesis : multiple factor advancing age or aggravating conditions, the weakly anchored hemorrhoids then gradually begin to bulge, and "slide" into the anal canal. by Hypertrophy or increased tone of the internal anal sphincter, the fecal bolus forces the hemorrhoidal plexus against the internal sphincter during defecation causes them to enlarge. Abnormal distension of the arteriovenous anastomoses within the hemorrhoidal cushions Abnormal dilatation of the veins of the internal hemorrhoidal venous plexus.

6. Liver cirhosis not cause hemorrhoid but may associated with severe bleeding through the hemorrhoid as coagulopathy. External hemorrhoid painful without bleeding as ( thick layer of muscosa ) and usually associated with thrombosis.

7. Clinical features: History : Age : occur any ages but uncommon below 20 years and extremely rare in children. Symptoms of internal hemorrhoids Non-complicated complicated Asymptomatic (40%) Bleeding : Painless Bright red blood coat with stool at the end of defecation or drip in toilet. Associated with bowel movement or spontaneous. Exacerbated by straining Chronic bleeding cause iron deficiency anemia Mild fecal incontennece Mucus discharge Wetness or fullness sensation in perianal area in case of prolapse hemorrhoids Irritation or itching in perianal skin.

8. Clinical features: In complicated hemorrhoid : acute onset of perianal pain and a palpable perianal "lump" from thrombosis ( more common in external hemorrhoid). internal hemorrhoids become prolapsed, strangulated, and develop gangrenous changes. Diagnosis: Clinical diagnosis Laboratory : - For anemia. Endoscopic evaluation : Including anoscopy and colonoscopy. in all patient with malena or hematochezia . all patient above 40y and those who suspicious of malignancy.

9. Differential diagnosis: anal fissures solitary rectal ulcer syndrome colorectal and anal cancer rectal prolapse  polyps

10. Management: according to grade and complication Conservative therapy Non surgical office-based procedure ( rubber banding – sclerotherapy ….) No Definitive surgical treatment ( hemorrhoidectomy ) No Complication of banding : commonly pain and infection perianal skin irritation. Bleeding less common Complication: commonly urinary retention pain – infection - Bleeding less common

11. Conservative treatments: High fiber diet to reduce constipation. oral or local analgesics to treat pain topical steroids agents to reduce local swelling or treat contact dermatitis ( hydrocortisol ) therapies to reduce sphincter spasm venoactive agents to increase venous tone of hemorrhoidal tissues Sitz baths also help to relieve irritation and pruritus Change of Toilet habits. Non surgical office-based procedure: Rubber banding Sclerotherapy : Injectable sclerosant solutions can also be used to treat symptomatic internal hemorrhoids. causes an intense inflammatory reaction, destroying redundant submucosal tissue associated with hemorrhoidal prolapse .